March 2017

In this Issue: VA Healthcare for Women Veterans
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Patient-Centered Approach to Insomnia Treatment for Women Veterans

Feature Article

Insomnia (defined as sleep disturbance that is sufficiently severe to cause distress or impact functioning) is a significant public health concern that contributes to lost productivity, psychological distress, medical morbidity, and mortality risk. Complaints about insomnia are more common among women than men, with a mean prevalence of more than 23% among US women. In 2011, HSR&D investigators completed the first descriptive study of sleep problems among women Veterans who receive VA healthcare and found high rates of insomnia (54% of study respondents) and comorbid conditions that may impact treatment acceptability and delivery. They also found that women Veterans with insomnia preferred non-medication treatments over medications, and that they were most likely to access this treatment if it were delivered in individual format (rather than groups).

This randomized trial compares Acceptance of the Behavioral Changes to treat Insomnia (ABC-I) with Cognitive-Behavioral Therapy for Insomnia (CBT-I). Investigators will compare:

• Dropout rates and adherence to behavioral recommendations between the ABC-I program and a similarly-structured CBT-I program;
• Effectiveness of the ABC-I in improving sleep/wake patterns from baseline to post-treatment to a similarly-structured CBT-I program;
• Maintenance of improvements in sleep/wake patterns across the two treatment programs three months after the end of treatment.

A brief survey is being sent to women Veterans who received VA healthcare in the Los Angeles region. Women who return the survey indicating symptoms of insomnia are being contacted by phone and invited to participate in the treatment study. Thus far, 252 women Veterans have been enrolled, and 110 have been randomized to one of the two treatment programs. The insomnia treatment programs are provided in 5 one-on-one sessions to women Veterans with insomnia by trained interventionists. Adherence to treatment recommendations and treatment completion rates are being measured in both treatment groups. Sleep quality (self-reported and objectively measured), psychiatric symptom severity, and quality of life are assessed at baseline (before treatment), post-treatment, and at three-month follow-up.

Impact: If effective, ABC-I and CBT-I will represent two desirable treatment options that are consistent with the preferences of women Veterans with insomnia. Findings from this study may ultimately improve the variety of available behavioral treatments for insomnia within VA and improve important health and quality of life outcomes among women Veterans who receive VA healthcare. Findings from this study also may provide information about the relationship between sleep and psychiatric comorbidities in women Veterans.

Principal Investigator: Jennifer L. Martin, PhD, is part of HSR&D's Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and the Geriatric Research, Education and Clinical Center (GRECC) in Los Angeles, CA.

Culver N, Song Y, McGowan S, et al., and Martin J. Acceptability of medication and non-medication treatment for insomnia among female Veterans: Effects of age, insomnia severity, and psychiatric symptoms. Clinical Therapeutics. November 2016;38(11):2373-2385.

Martin J, Schweizer C, Hughes J, et al. Estimated prevalence of insomnia among women Veterans: Results of a postal survey. Women's Health Issues. January 2017; Epub ahead of print.

Patient-Centered Approach to Insomnia Treatment for Women Veterans project abstract